For headache, there are no specific tests prescribed. However, imaging, represented by CT and MRI, is very useful in detecting intracranial organic lesions. Appropriate imaging can be easily explained to the patient and understood by the patient. For example, if a patient is worried about having a brain tumor, then a negative result of CT or MRI is very meaningful. “It is better to hear than to see.” Patients who see that they do not have a tumor in their brain under the guidance of their doctor will be very relieved.
Imaging is even more necessary if one encounters the following.
1, Sudden headaches that have never been experienced before.
2.Limited headache in the eye, etc.
3. headache with positive signs of the somatic and nervous system.
4. daily morning headaches. For these headaches it is necessary to think of organic diseases.
For a patient with headache, the following tests need to be selected according to the situation.
1. Blood pressure measurement, electrocardiogram and blood tests.
Whatever the case, do not forget to measure blood pressure. Patients with headache, many of them are hypertensive patients who are not systematically treated. Secondly, the contraindications to the specific drugs for migraine, such as treprostin, are hypertension, liver damage, previous history of cerebrovascular disease and myocardial infarction, and ischemic heart disease. It is important to know if there are any of these contraindications before using the drug. Previous myocardial infarction or suspected angina pectoris requires an electrocardiogram. In addition, blood tests are required for first-time patients. Vasculitis represented by temporal arteritis and cavernous sinusitis may have inflammatory manifestations such as leukocytosis in peripheral blood, increased sedimentation, and positive CRP.
2. Head CT.
CT of the head is very meaningful to determine intracranial organic lesions. the CT can detect lesions that are not expected from the interrogation or physical examination. A large proportion of headache patients are uneasy about “brain disease” and want to have imaging tests such as CT of the head; with CT photos, they can be shown and explained to the patient. Hemorrhage and calcification, which are more sensitive and rapid than MRI. It is also significant for the diagnosis of cerebral hemorrhage, subarachnoid hemorrhage, subdural hemorrhage, and epidural hemorrhage. Calcifications can suggest craniopharyngioma, meningioma, teratoma, astrocytoma, ventricular meningioma, and chordoma. Enhanced CT must be done when primary or metastatic brain tumors are suspected. in meningitis, the enhancing effect of meninges on the brain surface can be seen.
3. Magnetic resonance of the head and magnetic resonance angiography (MRI/MRA).
To find the cause of secondary headache, CT examination is mostly fast and effective. However, MRI is still the most suitable for tumorigenic lesions, inflammatory lesions, cerebral edema, lesions in the posterior cranial fossa and periorbital area surrounded by bone, and sinuses. MRI is also useful for inflammatory diseases of the meninges, such as hypertrophic duralgia, and cancerous meningitis.
Idiopathic low cranial pressure headaches are worse when standing and less severe when lying down. Dural enhancement seen on gadolinium contrast MRI is characteristic of this disease. MRA is useful for detecting cerebral aneurysms, but it is important to note that its accuracy is not very high.
4. Simple X-ray of the head.
Due to the progress of medical technology, CT and MRI examinations have become more popular in China, and simple X-rays of the head are almost eliminated. However, the shape of the pterygoid saddle and the situation of the atlantoaxial union at the base of the skull can be seen on the X-ray lateral image, and sometimes there is still some significance. In the case of parabrachial saddle tumors and pituitary tumors, changes in the saddle nodes, anterior bed prominence, posterior bed prominence, pituitary fossa, and saddle dorsum can be observed. Congenital lesions of the atlanto-axial union of the skull base such as skull base depression or flat skull base can also be the cause of head and neck pain. In chronic intracranial hypertension, separation of bony sutures is seen in pediatric patients, and in adults, increased finger indentation and changes in the pterygoid saddle.
5. Simple x-ray of the cervical spine.
The cause of headache is not necessarily limited to the head. Deformational cervical spondylosis can also cause pain in the occipital area or head and neck. Cervical simple X-ray can observe the loss of physiological protrusion or scoliosis of the cervical spine, deformation of the vertebral body and narrowing of the intervertebral space. There are 7 directions of simple cervical spine camera: orthogonal, double oblique, lateral (anterior flexion, neutral, posterior flexion) and frontal open position, and the necessary examination should be used according to the situation.
6, cerebral angiography (DSA).
Although cerebral angiography is a more invasive test in headache examination, it is the best test for vascular lesions such as aneurysm or venous sinus thrombosis that are difficult to detect with CT and MRI. The headaches that cannot be missed include those caused by intracranial entrapment aneurysms, which are more common in young people. Those with hemorrhage have a very dangerous prognosis when they add the pain of subarachnoid hemorrhage on top of the pain of damage to the vessel wall. Cerebral angiography can easily detect such lesions.
7. Electroencephalogram.
For the diagnosis of epileptic headache EEG is necessary. The presence of epileptic seizure waves is the main point of diagnosis. However, patients with migraine can sometimes present with epileptic EEG abnormalities, especially in certain pediatric headache patients who present with epileptic seizure waves and whose antiepileptic drugs are effective. Most of these are simple partial attacks (autonomic seizures), which are headaches characterized by sudden onset, mostly accompanied by nausea, vomiting, and post-ictal sleepiness or drowsiness, similar to migraine attacks. Some cases have both features, suggesting that there may be pathophysiological correlation between the two.
8. Cerebrospinal fluid examination.
For headache suspected of subarachnoid hemorrhage, headache with signs of meningeal irritation or inflammatory manifestations, and headache of unknown origin, it is necessary to examine the cerebrospinal fluid. A lumbar puncture can determine the level of cranial pressure, hemorrhage, yellowing and the presence of meningitis. In particular, cerebrospinal fluid examination is necessary to identify the pathogenic bacteria causing meningitis.
However, when there is cervical ankylosis or optic nerve papilledema, increased intracranial pressure should be considered. At this time, lumbar puncture may cause death by herniation of the greater occipital foramen of the cerebellum due to a sudden decrease in cranial pressure, which is contraindicated in principle.
9. Ophthalmologic and otorhinolaryngologic examinations.
Ophthalmologic diseases are also one of the causes of secondary headache. In particular, acute attacks of closed-angle glaucoma can present with severe headache, eye pain, vomiting and vision loss. Pupillary asymmetry can also occur and may even be misdiagnosed as a subarachnoid hemorrhage, making it necessary to check intraocular pressure. In addition, examination of the fundus may indicate intracranial hypertension if optic papilla edema is found, or subarachnoid hemorrhage if subretinal hemorrhage is found.
Some intractable headaches are caused by sinusitis. Sinusitis has characteristic symptoms depending on the location of the disease. For example, frontal sinusitis starts with pain in the frontal area, the top of the head and the back of the orbits, and most headaches are worse in the morning and into the morning and lessen in the afternoon. In maxillary sinusitis, the pain is in the face, especially in the cheeks or ears, and radiates upward to the alveolar and frontal areas. Pain in septal sinusitis radiates from the interorbital area, nasal root, medial canthus, or postorbital area to the temporal region. Pterygoid sinusitis presents with pain in the occipital, apical, frontal, and posterior orbital areas. These sinusitis can be improved with appropriate treatment. The neurologist should refer the patient to an otolaryngologist for treatment based on the above features.